|Year : 2020 | Volume
| Issue : 6 | Page : 277-281
The simple solution for infertile patients with aspermia in the modern era of assisted reproductive technique
Le-Wei Fan1, I-Hung Shao2, Ming-Li Hsieh1
1 Department of Surgery, Division of Urology, Chang Gung Memorial Hospital, Linkou, Taiwan
2 Department of Surgery, Division of Urology, Chang Gung Memorial Hospital, Linkou; Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan
|Date of Submission||06-Aug-2020|
|Date of Decision||30-Sep-2020|
|Date of Acceptance||13-Oct-2020|
|Date of Web Publication||26-Dec-2020|
Department of Surgery, Division of Urology, Chang.Gung Memorial Hospital, Linkou Branch, No. 5, Fuxing Street, Guishan District, Taoyuan City
Source of Support: None, Conflict of Interest: None
Purpose: The purpose is to investigate the feasibility and outcomes of loupe-assisted vasostomy for sperm retrieval in male infertility due to anejaculation or retrograde ejaculation. Materials and Methods: We retrospectively reviewed the vasal sperm aspirations of 9 patients with anejaculation or retrograde ejaculation from 2015 to 2017. We collected preoperative serum hormone data (testosterone, follicle-stimulating hormone, luteinizing hormone, and prolactin) and comorbidities of each patient. The patients underwent standard loupe-assisted modified vasostomy by a single surgeon with immediate specimen interpretation, with follow-up at the clinic. Results: Of the 9 patients, 4 had retrograde ejaculation, and 5 had anejaculation. Seven patients had controlled diabetes mellitus; of them, one had an ejaculating duct stone, and only one had no comorbidity. Aspirations were performed for sequential assisted reproductive techniques in 7 patients and cryopreservation in another two. The average total sperm count was 213 × 106, with motility between 9% and 67% and normal sperm morphology between 4.5% and 50.0%. One patient had undergone microsurgical epididymal sperm aspiration before vasal aspiration, but the semen analysis indicated poor sperm quality and could not be used for in vitro fertilization. In total, 7 of the 8 aspirations (87.5%) resulted in pregnancy. No complications have been observed to date. Conclusion: Vasal sperm aspiration is a simple and effective alternative method for sperm retrieval, with the advantage of a high success rate and less invasiveness and destruction of the reproductive system. It may be performed before sperm retrieval from the epididymis or testis in infertile men with aspermia.
Keywords: Aspermia, diagnostic and therapeutic procedure, male infertility, sperm retrieval, vasostomy
|How to cite this article:|
Fan LW, Shao IH, Hsieh ML. The simple solution for infertile patients with aspermia in the modern era of assisted reproductive technique. Urol Sci 2020;31:277-81
|How to cite this URL:|
Fan LW, Shao IH, Hsieh ML. The simple solution for infertile patients with aspermia in the modern era of assisted reproductive technique. Urol Sci [serial online] 2020 [cited 2021 Jan 17];31:277-81. Available from: https://www.e-urol-sci.com/text.asp?2020/31/6/277/305091
| Introduction|| |
Vasal aspiration of sperm is a safe and effective retrieval method in men with aspermia, which has been reported since the 1990s but is still not widely known and applied in patients with aspermia. Aspermia is defined as a complete lack of semen expulsed from the urethral meatus also referred to as a dry ejaculate. Aspermia may occur either because of an inability to produce semen or because of an inability to ejaculate in an antegrade direction. Aspermia may be broadly classified as either anejaculation (lack of emission) or retrograde ejaculation. Disorders of ejaculation are uncommon but important causes of male infertility. Ideally, the goal of treatment is to establish antegrade ejaculation. Nonetheless, we must make the right diagnosis first and then seek a suitable treatment method for these individuals. We reviewed recent articles about the management of aspermia, and we may prescribe alpha-agonists and tricyclic antidepressants before artificially obtaining sperm by methods such as urinary sperm retrieval, prostatic massage, penile vibratory stimulation (PVS), and electroejaculation (EEJ). Sometimes more invasive methods, including vasal aspiration, microsurgical epididymal sperm aspiration (MESA), and microsurgical testicular sperm extraction (micro-TESE), even transurethral resection of ejaculatory duct, direct vision internal urethrotomy, and bladder neck reconstruction surgery,, are performed, depending on the etiology of the anejaculation or retrograde ejaculation and the facilities available at each institution. To achieve fertility, sometimes, these patients spend much time and money and bear complicated and unpleasant examinations to establish a possible diagnosis and treatment.
Although several studies have reported vasal sperm aspiration in patients with different etiologies, an explicit and executable consensus is lacking for the survey and treatment of infertile patients with aspermia. The purpose of this study was to elucidate the feasibility and role of loupe-assisted, modified vasal sperm aspiration in patients with aspermia and to optimize the sequencing of management of aspermia.
| Materials and Methods|| |
In this retrospective study, we examined the medical records of 9 men who were infertile due to dry ejaculation. They had clinical diagnoses of anejaculation or retrograde ejaculation and underwent 9 vasal aspirations for sperm retrieval. The average patient age at aspiration was 41.3 years (range: 35–51 years). The data collected from the medical records from January 2015 to December 2017 included demographic characteristics and sexual history. Each patient had undergone a complete physical examination, and serum sex hormonal screen, including testosterone, follicle-stimulating hormone (FSH), luteinizing hormone (LH), and prolactin, and previous trauma or surgical history and any comorbidity were recorded. Each patient underwent our modified procedure of unilateral vasal sperm aspiration by a single experienced surgeon at a tertiary medical center. The vasal sperm aspirate was immediately analyzed in our reproductive center laboratory after the specimen was obtained. This specimen was also processed for in vitro fertilization or cryopreservation at the same time. The institutional review board of Chang Gung Memorial Hospital approved this study (IRB approval number: 201900021B0) and all data collection. The patient consent was waived due to the retrospective study design.
The outpatient surgical procedure was performed with patients under local or general anesthesia. We first identified the vas deferens of the larger and more elastic testis on palpation and moved it laterally to the side of the scrotum with ring forceps. A 5 mm no-scalpel incision was made in the upper and lateral scrotum to expose the straight portion of the vas deferens. Then, a 1.5 cm segment of vas deferens was isolated from the surrounding fascia and vessels with the aid of loupe magnification and bipolar cautery for hemostasis to avoid increasing the difficulty of the sperm evaluation. One 2 mm longitudinal cut was made in the vas deferens with a number 11 Beaver blade, and the lumen was exposed. We placed a 24-gauge intravenous catheter into the lumen toward or opposite the testis to aspirate the semen with a 1 mL syringe; alternatively, we collected the irrigation fluid of about 0.1 mL of sperm-washing medium (Modified Human Tubal Fluid, Irvine Scientific, Santa Ana, CA, USA) from at least 3 receptacles for each vasal sperm aspiration. The epididymis and the proximal vas deferens were gently massaged to allow the mixing of the irrigant and semen. We paused the procedure until we received the results of the semen analysis and continued collection until we obtained adequate sperm count and quality. The vasostomy was then closed with the aid of loupe magnification (×3) using a half-layer technique with interrupted 9-zero nylon sutures (2–3 semithickness) [Figure 1]. Dartos fascia and skin were closed with 4–0 chromic suture.
|Figure 1: The modified vassal sperm aspiration. (a) Chosen vas deferens was identified and grasped by ring forceps; (b) a small segment of vas deferens was isolated from the surrounding fascia and vessels; (c) one 2-mm “longitudinal” cut was made; (d) placed a 24-gauge intravenous catheter to aspirate the semen|
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| Results|| |
The patient ages ranged from 35 to 51 years (mean: 41.3 years). The mean serum LH, FSH, and testosterone values were 3.82 ± 1.61 mIU/mL (range: 1.4–6.6 mIU/mL), 4.74 ± 1.97 mIU/mL (range: 2.2–9.0 mIU/mL), and 5.08 ± 2.50 ng/mL (range: 2.13–9.51 ng/mL), respectively. Of all patients, 4 had retrograde ejaculation, and 5 had anejaculation. There were 7 patients with controlled diabetes mellitus (DM), one with an ejaculatory duct stone, and only one without any comorbidity. Two patients had received drug therapy for concomitant erectile dysfunction, and another 2 patients had undergone transurethral resection of the ejaculatory duct and MESA by different surgeons, respectively. In contrast, the remaining five patients did not receive any medical therapy by choice or because of cost constraints [Table 1].
All 9 patients achieved satisfactory sperm retrieval. The average sperm count was 213 × 106 (range: 60–340 × 106), the average motility was 47.3% (range: 9%–66.7%), and 24.8% (range: 4.5%–50.0%) of the sperm had normal morphology. One patient who had undergone MESA had lower sperm motility and normal morphology percentage, but 2 sequential vasal aspirations achieved satisfactory results, and he achieved paternity. Intracytoplasmic sperm injection (ICSI) was performed in 7 of the couples and cryopreservation in the remaining 2 patients. Of these 7 attempts and one which was attempted 3 months after cryopreservation, 7 pregnancies (87.5%) were achieved, which resulted in 6 live term births and 1 preterm birth [Table 2].
The surgical procedure for sperm retrieval took <30 min on average. All patients had follow-up examinations. Postoperatively, all patients had no complaint of pain or difficulty with wound healing. The healing of the lumen of the vas deferens appeared sufficient to allow additional aspirations to be performed on the same side, as one patient successfully underwent a second aspiration from the same vas deferens after 3 months. Vas deferens patency was confirmed by vasal irrigation with 10 mL of sterile saline.
| Discussion|| |
After a thorough explanation and discussion, 5 of these 9 patients underwent vasal sperm aspiration without previous medical management because they preferred a more direct and sure artificial reproductive technique rather than the conservative but relatively slow response and uncertain success rates of other methods. Four patients had retrograde ejaculation diagnosed by their history, semen analysis, and postejaculate urine analysis. A previous review article reported a possibility of contaminated sperm and relatively low per-cycle pregnancy rates ranging from 20% to 50% with urinary sperm retrieval. Therefore, our patients chose a vasal sperm aspiration according to our recommendations.
There are many treatment modalities for vasal sperm aspiration that have been reported, including percutaneous vasal sperm aspiration (PVSA), no-scalpel vasal sperm aspiration, and microsurgical techniques. These methods have a high success rate and yield adequate quality sperm for preservation or sequential fertilization. Although some studies have shown repeatability, with successful harvest of sperm on the second attempt from the same vas, clinicians are still apprehensive about possible complications such as postoperative vasal stricture or obstruction and the possible need for later reconstructive surgery.
In this report, we describe a novel modification to our procedure. First, we changed the way we made the incision into the vas deferens. The vas was partially incised parallel rather than perpendicular to its axis with a No. 11 Beaver blade, down to the lumen, which allowed us to create a larger opening to improve the ease of vasal fluid aspiration. Moreover, this change reduced the tension to the vasostomy. We surmised that a wound incision parallel to the skin fold would enable us to reapproximate the vasal edge in the half-layer of the tunica adventitia and part of the tunica muscularis, without the necessity of stitches into the lumen. Thus, we could avoid causing crowding in this small space or an unexpected tissue reaction and stricture. Through this adjustment in the procedure, theoretically, we could maintain the patency of vas and make the procedure repeatable if necessary. We indeed successfully retrieved sperm at the same position in the vas twice in different patients. In addition, we suggest a relatively higher level of the skin incision site than the usually incised wound of a vasectomy because a vasal incision more distal to the epididymis improves the opportunity for repeat sperm aspiration without interference in sequential MESA/TESE if necessary by extending the original wound. The entire procedure can be performed precisely and clearly under 3× loupe magnification instead of an expensive operative microscope.
Compared to other existing treatment modalities for anejaculation and retrograde ejaculation, vasal sperm aspiration has several advantages. First, the most important factor is its high success rate; all patients (100%) obtain enough of a sample to undergo in vitro fertilization or cryopreservation. As in previous studies, regardless of the different procedures, sperm were retrieved in all cases.,,,, Second, the sperm quality, average sperm count, and motility percentage were higher than the World Health Organization reference values, which may improve the pregnancy rate. This may be one of the reasons for the high pregnancy rate in our population, although the factors in successful gravidity are complex and the quality of sperm is not a guarantee of paternity. Because testicular spermatozoa have limited motility and are, therefore, incapable of naturally fertilizing an egg, they need to be transferred to the epididymis to mature and become functional. Theoretically, the sperm in the vas deferens should be more physiologically similar to the sperm in a normal ejaculate and thus, more mature and motile than epididymal or testicular sperm. In addition, sperm retrieval from the epididymis using MESA is sometimes difficult in patients with aspermia because their ductus epididymidis is not dilated as those patients with obstructive azoospermia. We had one patient who had undergone MESA on the right side before vasostomy on the left side twice, and the sperm count, motility, and normal morphology of the sperm retrieved through vasal aspiration were all superior to those retrieved with MESA.
On the other hand, some studies demonstrated lower sperm motility or pregnancy rates after ICSI with the use of electroejaculated sperm compared to those of ejaculated sperm or sperm surgically retrieved from the patients with azoospermia., Brackett et al. reported that the motility of sperm retrieved from the vas deferens is often superior to that of sperm ejaculated as a result of PVS and EEJ in men with spinal cord injuries. Although motility is not directly related to the fertilizing ability of sperm, it is one of the most important factors affecting sperm quality. Several studies have documented that the motility of sperm decreases by 33%–50% after one freeze-thaw cycle., Therefore, the degree of mobility is one of the decisive factors for sperm cryopreservation. Third, our procedure is less invasive and destructive to the reproductive system, especially to the epididymis and testis, so that we can retain the opportunity to perform MESA and TESE as the final chance for those patients in whom other treatments fail. With loupe-assisted sperm retrieval from the vas deferens, the incision and sperm retrieval not only resulted in less damage to the vas and adjacent tissue but also caused minimal blood contamination during the procedure, which made interpretation of the sample characteristics quicker and easier. PVSA is indeed less invasive than loupe-assisted modified vasostomy. Considering the former is performed in a relatively blind way, it may take a lot of practice and experience to achieve success. Injury and possible sequential stricture could result from a poor technique. Another advantage is that the wound can be extended for further MESA or TESE if there is failure via the vas deferens. In addition, the procedure seemed to be repeatable at the same location in the vas deferens, probably because it is less destructive with a clear cutting and following the repair immediately, and the vas deferens remained patent. Levine and Fakouri reported a similar experience that successfully retrieved sperm at a different site of the same vas deferens. Fourth, patients prefer the ease and comfort of an office-based surgery and local or general anesthesia, without having to undergo drug therapy or PVS. Finally, safety is one of the reasons why our surgeon and patients preferred vasal sperm retrieval; there was no peri- or posto-perative complication among our patients. A review of the literature showed only rare and mild complications such as wound infection.
Although vasal sperm aspiration has been verified in previous studies as a reliable and effective assisted reproductive technique for the treatment of aspermia in neurogenic/nonreadable anejaculation or obstruction of the vas deferens, most urologists make MESA or TESE as their first choice if the patient with aspermia needs sperm retrieval for fertilization or cryopreservation. In today's era of assisted reproductive technologies, the success rate depends on several factors. One of the important factors is semen quality. Theoretically, vasostomy yields better semen quality than urinary sperm retrieval, PVS, EEJ, and even MESA and TESE, so that the infertile couple has a greater chance to conceive. In addition, vasostomy can be a diagnostic and therapeutic procedure at the same time, allowing a man with aspermia to avoid unnecessary examinations such as vasography and uncomfortable procedures such as testis biopsy, PVS, and EEJ. To the best of our knowledge, there is no consensus on the evaluation of infertile men with aspermia. Individualized treatment depending on clinical manifestations is recommended. In our institution, we usually follow the algorithm for evaluation of azoospermia proposed by Turek and adjust the strategy according to the preferences of the patient and clinician. Physical examination of the bilateral vas deferens and testes, in addition to the basic medical, personal, and familial history, is indispensable in patients with aspermia with paternity intentions. If no problems are found, hormonal levels including FSH, LH, and testosterone are checked and semen analysis is done if available. If there is no significant cause of aspermia such as α-blocker therapy or a history of DM, a transrectal ultrasound can be done. If the above examinations are within the normal range, a diagnostic testis biopsy is usually suggested. However, we recommend loupe-assisted, modified vasal aspiration as the first step in the diagnosis and treatment of infertile men with either retrograde ejaculation or anejaculation, especially when sperm cryopreservation and ICSI are anticipated. Since the patients may experience multiple procedures for sperm retrieval, we can place more invasive methods (MESA or micro-TESE) at the end of the treatment continuum to take advantage of this simple sperm retrieval method. This research is limited by small case numbers. We hope to improve the management of patients with aspermia with this novel modification. There are presently no studies that specifically compare the outcomes of different methods of sperm retrieval, so more cases and experiences are needed to verify the study results.
| Conclusion|| |
Loupe-assisted vasal sperm aspiration is a simple, safe, cost-effective, and less destructive technique with a high success rate to obtain viable, mature sperm, leading to good pregnancy outcomes. Considering both the minimal damage to the reproductive system including the epididymis and testis and the minimal surgical risk, vasal sperm aspiration should be the first diagnostic and therapeutic procedure for infertile men with aspermia rather than other complicated and time-consuming examinations or invasive surgery such as MESA or TESE.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2]